Carpal Tunnel Syndrome

Carpal tunnel syndrome, which encompasses a range of symptoms affecting the hands and wrists, is now the most common hand problem that primary-care physicians see. It has been estimated that millions of Americans presently have the syndrome, due primarily to their occupations.

Typical symptoms are persistent numbness, burning, and tingling of the hands, as if they had fallen asleep. These conditions are likely to worsen at night, and may even wake you up. Many people also experience stiff, swollen wrist joints and loss of hand strength and dexterity, especially when performing fine movements such as picking up a button or sewing.

The direct cause is pressure on the median nerve, which carries messages between the hand and brain. The carpal tunnel itself is a narrow opening in the wrist, made up of eight bones that form three sides of the tunnel, and the transverse carpal ligament, a tough band of tissue that forms the fourth side. The tunnel is situated on the palm side of the wrist, and nine tendons as well as the median nerve pass through it. If any of these tendons swells, or if an injury causes the space inside the tunnel to decrease, the median nerve may become irritated or pinched, leading to inflammation, swelling, and the characteristic symptoms.

Anyone whose job or hobby calls for repeating the same motions over and over, especially if the wrists are hyper-flexed or hypertextended, are vulnerable to the syndrome, which is also referred to as repetitive stress injury. Computer operators, pianists, meat packers, and jackhammer operators are among those who have a high risk of carpal tunnel syndrome. Pregnant women are also vulnerable to the disorder because of general tissue swelling and fluid retention, especially in the hands and feet.

Diagnostic Studies and Procedures

Two simple office tests point to a diagnosis of carpal tunnel syndrome. In one, called Phalen's test, you put the backs of your hands against each other with the wrists completely flexed. If you feel numbness, tingling, or pain within 60 seconds, the median nerve is probably compressed. In the second, called Tinel's test, the doctor will tap the palm area over the median nerve. Again, any tingling or numbness indicates median nerve compression.

The definitive diagnostic test, however, is electromyography (EMG). In this nerve conduction study, performed by a neurologist, electrical stimulation is used to detect any abnormal electrical activity when nerves and muscles are at rest and during contraction.

Medical Treatments

Treatment usually starts with rest and immobilization of the affected hand and wrist. Special splints may be used to hold the wrist in a straight, unflexed position. Some patients wear the splint only at night, while others require it all the time until symptoms abate.

Anti-inflammatory medications such as aspirin and ibuprofen may be prescribed, as well as muscle relaxants and stronger prescription pain relievers if needed. In more severe cases, cortisone injections directly into the wrist can provide dramatic relief of pain and inflammation, but will not permanently cure the condition.

Progression of the syndrome, marked by increasing pain, a weakening of grip strength, and shrinking of the muscles at the base of the thumb, calls for more intensive treatment. A removable cast, worn at all times except when showering or bathing, may be tried. If this does not produce improvement, surgery by a hand specialist may be necessary to release the trapped nerve. The surgery involves culling and releasing the transverse ligament, which relieves pressure on the median nerve. Many people report that their symptoms completely disappear right after surgery. The problems may return, however, with the resumption of the activities that produced them.

Alternative Therapies

Many doctors recommend a trial of these therapies before resorting to surgery. They can also be used as adjuncts to conventional treatment.

Acupuncture. Meridians affecting the neck, back, and shoulders as well as the hands, wrists, and arms are stimulated in an attempt to heal the entire length of the injured nerve.

Alexander Technique. A practitioner will assess your posture and movements and suggest changes that are likely to correct faulty habits that contribute to the syndrome.

Chiropractic Practitioners manipulate 9 misaligned or fixated joints to relieve m nerve pressure, and are likely to adjust 9 not only the wrist, but also the areas where the median nerve is connected to the rest of the nervous system, including the arm, shoulder, and neck. Adjusting the neck, or cervical spine, is considered particularly important.

Many chiropractors, as well as some acupuncturists, use transcutaneous nerve stimulation, or TENS, a method of relieving pain by delivering mild electrical pulses to the skin that cause the body to produce endorphins, its own natural painkillers.

Some chiropractors also use ultrasound and may recommend other alternanative approaches.

Nurririon Therapy and Naturopathy. Deficiencies of vitamins B6 and B,2 appear to play a role in some cases of carpal tunnel syndrome. A nutritionist can assess your diet and suggest taking supplements or eating foods rich in these vitamins, including meat, fish, and other animal products for both, plus whole grains, spinach, potatoes, and bananas for B6. Caution is needed, however, because excessive B6 also produces hand numbness and tingling.

Osteopathy. Osteopaths combine the medical training of a traditional physician with manipulation techniques. They are likely to emphasize exercising and stretching to increase range of motion and may also prescribe medication and perform surgery, if needed.

Physical Therapy. Doctors, chiropractors, and osteopaths often refer patients to a physical therapist as an important aspect of treatment. These therapists can teach proper work habits and correct posture, and also design a therapeutic exercise program tailored to specific needs. In addition, they may use hydrotherapy, electrotherapy, ultrasound, massage, and a new type of electrical treatment called interferential current therapy to restore function and alleviate pain.

Self-Treatment

The most fundamental aspect of self-treatment is keeping your wrists in proper alignment, neither overflexed nor overextended. Pay attention to the position of your hands and wrists, both when working and at ease. They should be comfortably straight.

Make sure your work environment is designed to minimize stress on your joints. If you work at a computer or desk, adjust your chair to a comfortable height that allows you to place your feet flat on the floor and sit up straight, with good support for the lower back. If your chair lacks support, place a cushion or a rolled-up towel in the small of your back.

A computer monitor should be at or a little below eye level, and documents should be placed in a holder that keeps you from craning or bending your neck. Use a wrist rest if you spend a good pan of your day at the keyboard; these are sold in most computer stores, or you can fashion one from a folded towel. Don't angle your head forward, but keep it aligned straight above your spine. Try to avoid slouching.

Stand up and walk around whenever possible, for example, while talking on the phone or reading mail. In any event, take brief breaks at least once every hour, and perform the following simple exercises in a silting position.

• Cross your arms over your head and take your right elbow in your left hand. Pull the elbow toward your opposite arm and hold it for a few seconds. Repeat with the other elbow.
• Raise one arm over your head, then reach around to the opposite ear. Pull your head toward your shoulder for 10 seconds, reverse position and repeat with the other arm.
• Clasp your hands behind your head. Without letting your shoulders come up, gently try to move your elbows backward for five seconds or more.
• With your hands in your lap, make circles with your shoulders, rolling them forward, upward, and back while maintaining your head and neck in straight alignment. Do this five times, then reverse the circle and roll your shoulders from back to front five times.
• Limber up your hands by massaging and stretching your fingers, bending your wrist back and forth, and clenching and unclenching your fist.

Other Causes of Hand and Wrist Symptoms

Some systemic diseases, such as rheumatoid arthritis, diabetes, and thyroid disease, are associated with carpal tunnel syndrome. Certain nerve and circulatory disorders, such as Raynaud's syndrome, can cause hand numbness and tingling. A fractured or dislocated wrist that is not properly set or a herniated disc in the cervical spine can also trigger the symptoms of carpal tunnel syndrome.